Scholarly article on topic 'Cord Blood Transplantation from Unrelated Donors in Adults with High-Risk Acute Myeloid Leukemia'

Cord Blood Transplantation from Unrelated Donors in Adults with High-Risk Acute Myeloid Leukemia Academic research paper on "Clinical medicine"

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Abstract of research paper on Clinical medicine, author of scientific article — Jaime Sanz, Miguel A. Sanz, Silvana Saavedra, Ignacio Lorenzo, Pau Montesinos, et al.

Clinical studies focused on disease-specific outcomes of cord blood transplant (CBT) from unrelated donors are limited. We analyzed the outcome and prognostic factors of 49 adults with high-risk acute myelogenous leukemia (AML) receiving single-unit CBT from unrelated donors after myeloablative (MA) conditioning at a single institution. Conditioning regimens were based on the combination of thiotepa, busulfan (Bu), cyclophospamide (Cy), or fludarabine (Flu), and antithymocyte globulin (ATG). Cumulative incidence of myeloid and platelet engraftment was 96% and 73% at a median time of 20 and 62 days, respectively. Engraftment was significantly faster for patients receiving higher doses of CD34+ cells. Confidence Interval of graft-versus-host disease (GVHD), acute GVHD (aGVHD) grade II-IV, III-IV, and extensive chronic GVHD (cGVHD) were 26%, 15%, and 30%, respectively. Leukemia-free survival (LFS), nonrelapse mortality (NRM), and relapse at 2 years were 42%, 39%, and 19%, respectively. Low number of total nucleated cells (TNC) had a negative impact on NRM and LFS. Patients transplanted in first complete remission (CR1) receiving TNC above 2 × 107/kg had a 4-year LFS of 75%. These results show that CBT from unrelated donors is a curative treatment for a substantial number of patients with high-risk AML, particularly if transplant is performed with highly cellular units in patients in first CR.

Similar topics of scientific paper in Clinical medicine , author of scholarly article — Jaime Sanz, Miguel A. Sanz, Silvana Saavedra, Ignacio Lorenzo, Pau Montesinos, et al.

Academic research paper on topic "Cord Blood Transplantation from Unrelated Donors in Adults with High-Risk Acute Myeloid Leukemia"

ASBMI

American Society for Blood and Marrow Transplantation

Cord Blood Transplantation from Unrelated Donors in Adults with High-Risk Acute Myeloid Leukemia

Jaime Sanz,1'2 Miguel A. Sanz,1 Silvana Saavedra,1 Ignacio Lorenzo,1 Pau Montesinos,1

Leonor Senent,1 Dolores Planelles,3 Luis Larrea,3 Guillermo Martín,1 Javier Palau,1 Isidro Jarque,1 Jesus Martinez,1 Javier de la Rubia,1 Federico Moscardo,1 Monica Romero,1 Irene Luna,1 Alberto Montava,1 Sergio Canabate,1 Guillermo F. Sanz1

Clinical studies focused on disease-specific outcomes of cord blood transplant (CBT) from unrelated donors are limited. We analyzed the outcome and prognostic factors of 49 adults with high-risk acute myelogenous leukemia (AML) receiving single-unit CBT from unrelated donors after myeloablative (MA) conditioning at a single institution. Conditioning regimens were based on the combination of thiotepa, busulfan (Bu), cyclo-phospamide (Cy), or fludarabine (Flu), and antithymocyte globulin (ATG). Cumulative incidence of myeloid and platelet engraftment was 96% and 73% at a median time of 20 and 62 days, respectively. Engraftment was significantly faster for patients receiving higher doses of CD34 cells. Confidence Interval of graft-versus-host disease (GVHD), acute GVHD (aGVHD) grade II-IV, III-IV, and extensive chronic GVHD (cGVHD) were 26%, 15%, and 30%, respectively. Leukemia-free survival (LFS), nonrelapse mortality (NRM), and relapse at 2 years were 42%, 39%, and 19%, respectively. Low number of total nucleated cells (TNC) had a negative impact on NRM and LFS. Patients transplanted in first complete remission (CR1) receiving TNC above 2 x 107/kg had a 4-year LFS of 75%. These results show that CBT from unrelated donors is a curative treatment for a substantial number of patients with high-risk AML, particularly if transplant is performed with highly cellular units in patients in first CR.

Biol Blood Marrow Transplant 16: 86-94 (2010) © 2010 American Society for Blood and Marrow Transplantation KEY WORDS: Umbilical cord blood, Transplantation, Acute myeloid leukemia

INTRODUCTION

Patients with high-risk acute myelogenous leukemia (AML) have few chances of cure without allogeneic hematopoietic stem cell transplantation (HSCT). However, the application of this procedure is limited by the availability of suitable human leukocyte antigen (HLA)-compatible donors. Umbilical cord blood (UCB) has emerged as an alternative stem cell source for patients lacking HLA-matched adult donors [1].

Clinical experience has shown that CB transplantation (CBT) from unrelated donors (UDs)

From the 'Department of Hematology, Hospital Universitario La Fe, Valencia, Spain; Department ofMedicine of the Universitat Autónoma de Barcelona, Barcelona, Spain; and Centro de Trasfusión de la Comunidad Valenciana, Valencia, Spain. Financial disclosure: See Acknowledgments on page 93. Correspondence and reprint requests: Jaime Sanz, MD, Department of Hematology, Hospital Universitario La Fe, Avda Campanar 21, Valencia, Spain (e-mail: sanz_jai@gva.es). Received July 8, 2009; accepted September 2, 2009 © 2010 American Society for Blood and Marrow Transplantation 1083-8791/10/161-00010$36.00/0 doi:10.1016/j.bbmt.2009.09.001

compared to bone marrow transplantation (BMT) provides at least similar survival in children with acute leukemia [2,3]. For adults, registry-based studies have established CBT as a safe and feasible alternative to BMT when a matched sibling donor is not available [4,5]. However, information on disease-specific outcomes, in particular patients with AML treated with CBT from UDs, is very limited. In fact, it is restricted to 2 subsequent reports from the University of Tokyo [6,7] plus 2 additional registry-based reports, from Eurocord and the European Blood and Marrow Transplant Group (EBMT) [4] and from the Japan Marrow Donor Program (JMDP) and the Japan Cord Blood Bank Network (JCBBN) [8], both mainly focused on comparing CBT with BMT in patients with acute leukemia, including both AML and acute lymphoblastic leukemia (ALL).

We here report the outcome of a series of adults with AML who received CBT from UDs at a single institution. Apart from confirming the safety and efficacy of the procedure in this specific disease, an additional aim of the study was to identify variables influencing short- and long-term outcomes.

PATIENTS AND METHODS

Eligibility Criteria

This report constitutes a retrospective review of all 49 consecutive adult patients with AML who underwent a CBT from unrelated donors at our institution between June 2000 and November 2009. Patients were eligible for enrolment if they met the following criteria: (1) high-risk AML, defined by either high-risk cytogenetics or poor prognosis gene markers, more than 1 cycle to achieve complete remission (CR), or disease status beyond first CR; (2) not suitable related donor (HLA-identical or 1-antigen-mismatched); (3) need for an urgent transplantation or lack of HLA-identical UD after searching in the international registries for no more than 3 months; and (4) an available CB unit fulfilling minimum established criteria for both HLA compatibility between donor and recipient and cell dose. In this regard, CB units had to share at least 4 HLA antigens with the recipient (HLA class I antigens [A and B] determined by serologic or low-resolution DNA typing and class II antigens [DRB1] by high-resolution DNA typing). As per cell dose, total nucleated cells (TNC) higher than 1.5 x 107 per kilogram of the recipient's body weight were required until May 2006. Thereafter, TNC higher than 2 x 107 per kilogram of the recipient's body weight and CD341 cells higher than 1 x 105 per kilogram of the recipient's body weight were mandatory. The institutional review board approved the protocol, and written informed consent was obtained from all patients according to the declaration of Helsinki.

CB Unit Selection and Management

The search of CB units was conducted by the Spanish Registry of Bone Marrow Donors (Registro Español de Donantes de Medula (Osea). Among the available CB units fulfilling the minimum established criteria, units with higher cell dose, considering both TNC and CD341 cells, and higher HLA compatibility were selected across the study period. Additionally, ABO compatibility and year of storage were also considered. All CB units tested negative for human immunodeficiency virus (HIV), hepatitis B and C viruses (HBV, HCV), as well as human T cell lymphotropic virus type I. All CB units and mothers were negative for immunoglobulin M antibody to cytomegalovirus (CMV).

Thawing of CB units was performed by Rubinstein et al's method [9], with minor modifications as described elsewhere [10]. Before infusion, a sample was drawn directly from the bag for cell counts, including CD341 cells [11], cell viability, clonogenic assays [12], and microbiology.

Table 1. Graft- and Transplantation-Related Characteristics*

Cord blood unit supplier, no. (%)

Barcelona Cord Blood (CB) Bank 10 (20)

Australian CB Bank 8(16)

New York Blood Center 7 (|4)

Others 24 (49.0) HLA compatibility, no. (%)f

6 of 6 4 (8)

5 of 6 19(39)

4 of 6 25 (5|)

3 of 6 1 (2) ABO blood group mismatch, no. (%)

Major 7(13)

Minor 16(33)

None 25 (52) Donor-recipient sex match, no. (%)

Male-male 13 (27)

Male-female 9 (|8)

Female-male 17 (35)

Female-female 10 (20) KIR-ligand incompatibility in graft-versus-host direction, no. (%)

Yes |4 (29)

No 35(7|) Time elapsed between cord blood storage and transplantation, mo

Median 48

Range 10-212 Year of transplantation, no. (%)

2000-2005 |7 (35)

2006-2008 32 (65) Conditioning regimen, no. (%)

TT + Bu + Cy + ATGj 16(33)

TT + Bu + Flu + ATG:|: 33 (67) Graft-versus-host disease prophylaxis, no. (%)

Cyclosporine A + Prednisone 37 (75)

Cyclosporine A + MMF 12 (25) No. of nucleated cells before freezing, x l07/kg

Median 2.7

Range 1.4-5.5 No. of nucleated cells infused, x l07/kg

Median 2.2

Range 1.0-4.4 No. of CD34+cells before freezing, x l05/kg

Median 1.6

Range 0.17-4.05 No. of CD34+cells infused, x l05/kg

Median 1.2

Range 0.09-6.09

HLA indicates human leukocyte antigen; KIR, killer cell immunoglobulin-like receptor; TT, tiothepa; Bu, busulfan; Cy, cyclophosphamide; Flu, flu-darabine; ATG, antithymocyte globulin; MMF, mycophenolate mofetil.

*Percentages may not sum to 100 because of rounding. fThiotepa 5 mg/kg/day on days —9 and —8, oral busulfan 1 mg/kg/6 h or intravenous (i.v.) busulfan 0.8 mg/kg/6 h or on days —7 to —5, cyclophosphamide 60 mg/kg/day on days —4 and —3 and ATG on days —5 to —2 (Lymphoglobuline®, Merieux, Lyon, France, 15 mg/kg/day; or Thymoglo-bulin®, Sangstat/Genzyme, Lyon, France, 2 mg/kg/day). ^Thiotepa 5 mg/kg/day on days —7and —6, i.v. busulfan 3.2 mg/kg as asingle daily dose on days —5to — 3, fludarabine 50 mg/m2/day on days —5to —3 and ATG (Thymoglobulin®, 2 mg/kg/day on days —5 to —2 in 21 patients and 2 mg/kg/day on days —4 to —2 in the last 12 patients).

Conditioning Regimen

Myeloablative (MA) conditioning regimens were all based on the combination of thiotepa, busulfan (Bu), cyclophospamide (Cy), or fludarabine (Flu), and antithymocyte globulin (ATG) (Table 1). Until June 2006, 16 patients received thiotepa, Bu, Cy, and ATG. From June 2006, Cy was substituted by Flu.

Thirty-three patients received thiotepa, i.v. Bu as a single daily dose, Flu, and ATG.

Graft-versus-host disease (GVHD) Prophylaxis and Treatment

All patients received cyclosporine (CsA) 1.5 mg/kg/ 12 h i.v., followed by 3-5 mg/kg/12 h orally when oral intake was possible, with slow tapering starting between day +90 and +180 and discontinuation on day + 180 or before if feasible. CsA was combined with prednisone in the first 37 patients (0.5 mg/kg/day on days +7 to +14, 1 mg/kg/day on days +14 to +28, with slow tapering to discontinue on day +180) [13] or mycophenolate-mofetil (MMF) 15 mg/kg/12 h until day + 28 in the following 12 patients.

Patients developing acute GVHD (aGVHD) received high-dose methylprednisolone as initial therapy (20 mg/kg/day; halving the dose every 3 days until reaching 1 mg/kg/day, and then gradually tapered) as described by Bacigalupo et al. [14], followed by ATG in refractory cases. Chronic GVHD (cGVHD) was treated with prednisone 1 mg/kg/day.

Supportive Care

Patients were nursed in high-efficiency particulate air (HEPA)-filtered rooms. Intravenous access was achieved with a double-lumen tunneled central venous catheter. Granulocyte colony-stimulating factor (G-CSF) was administered subcutaneously 5 mg/kg/day from day +7 until neutrophil engraftment. All patients received oral ciprofloxacin (500 mg/12 h) as antibacterial prophylaxis. Prophylaxis against Pneumocystis jiro-veci consisted of cotrimoxazole (320/1600 mg trimethoprim/sulfamethoxazole daily) from day —10 to day —2, and then restarted after engraftment to maintain a minimum of1 year or until stopping immu-nosuppresion (2 days a week). Fluconazole (100 mg/ day orally) was administered as antifungal prophylaxis in some patients at the beginning of the study period. From November 2003, fluconazole was substituted by i.v. itraconazole (200 mg/day). All blood products were irradiated and leukocyte depleted. CMV prophylaxis, infection surveillance, and treatment has been described in detail elsewhere [15]. Nonspecific i.v. immunoglobulin was administered at a dose of 500 mg/kg weekly until day +100 and then monthly during the first year after transplantation.

Definitions

Treatment outcomes were assessed according to the revised criteria by Cheson et al. [16]. Myeloid en-graftment was defined as an absolute neutrophil count (ANC) of 0.5 x 109/L or greater on 3 consecutive days. Platelet engraftment was defined as a platelet count of20 x 109/L or higher, without transfusion support, for 7 consecutive days. Patients who survived

more than 28 days after transplantation and who failed to achieve myeloid engraftment were considered as graft failures. Time to myeloid or platelet engraftment was defined as the time required to reach the first day of engraftment. Secondary graft failure was defined as the loss ofthe engraftment. aGVHD and cGVHD were defined and graded according to standard criteria [17-19]. Killer cell immunoglobulin-like receptor (KIR)-ligand compatibility was defined as described by Willemze et al. [20]. Briefly, KIR-ligand compatibility in the graft-versus-host (GVH) direction was determined according to whether or not they expressed HLA-C group 1 or 2, HLA-Bw4 [21] or HLA-A3/-A11 [22].

Statistical Analysis

The probability of engraftment, nonrelapse mortality (NRM), GVHD, and relapse was estimated by the cumulative incidence method (marginal probability) [23,24]. For cumulative incidence analysis of en-graftment, GVHD, and relapse, death in CR was considered as a competing cause of failure, whereas for NRM relapse was considered the competing event. Unadjusted time-to-event analyses were performed using the Kaplan-Meier estimate [25], and, for comparisons, the log-rank tests [26]. Leukemia-free survival (LFS) was calculated from the date of CBT. In the analysis of LFS, relapse and death in CR were considered uncensored events, whichever occurred first. Variables considered for prognostic factor analysis were: age, gender, recipient weight, recipient CMV serology, disease status at transplant, HLA compatibility, ABO blood group mismatch, donor-recipient sex match, KIR-ligand incompatibility, year of transplantation, conditioning regimen, GVHD prophylaxis, and TNC and CD34+ cells before freezing and infused. Continuous variables were dichotomized at the most discriminative cutoff point for each outcome. Variables with a value of P < .10 for each end point were tested in multivariate analysis using the Cox proportional hazards model for temporal events [27]. The follow-up of the patients was updated on February 15, 2009. All P-values reported are 2 sided. Except for the cumulative incidence method, computations were performed using the appropriate programs from the BMDP statistical library (BMDP Statistical Software, Los Angeles, CA) [28].

RESULTS

Patient Characteristics

Table 2 shows the characteristics of the 49 adult patients with AML who underwent CBT from unrelated donors. Briefly, 30 patients were males and 19 females with a median age of 34 years (range: 16-52 years). Thirty CB recipients (61%) were transplanted in first CR (CR1). The remaining 19 patients had

Table 2. Characteristics of Patients with AML Undergoing UCBT*

No. of patients 49

Age, years

Median 34

Range 16-52

Age group, no. (%)

16-20 years 4(8)

21-30 years 13(27)

31-40 years 17(35)

41-50 years 13(27)

>50 years 2(4)

Sex, no. (%)

Male 30 (61)

Female 19 (39)

Weight, kg

Median 71

Range 47-112

Disease status at transplant, no. (%)

First complete remission 30 (61)

Second complete remission 6(12)

Third or subsequent complete remission 2 (5)

Active disease (primary refractory or relapsed leukemia) 11 (22)

Diagnosis

De novo 42 (86)

Therapy- or MDS-related secondary AML 7(14)

Cytogenetics

Favorable 1 (2)

Intermediate 20 (41)

Poor 19 (39)

Unknown 9(18)

Previous autologous transplant 5(I0)j

Cytomegalovirus serologic status before transplantation, no. (%)

Positive 37 (75)

Negative I2 (25)

High-risk features for patients in first CR (n = 30)

Poor risk cytogenetics^ 6 (20)

$ 2 cycles of induction therapy to achieve CR§ II (37)

Poor risk cytogenetics and $2 cycles of induction therapy to 5(17)

achieve CR

Other§ 8 (27)

Time from diagnosis to transplantation for patients in first CR, mo

Median 6

Range 3.9-9.1

AML indicates acute myelogenous leukemia; CR, complete remission;

MDS, myelodysplastic syndrome; UCBT, umbilical cord blood transplant.

*Percentages may not sum to 100 because of rounding.

fOne patient underwent 2 autologous transplants.

^Poor risk cytogenetics included: complex karyotype, del(7q)/—7,

t(6;9), EVII, t(9;22), MLL rearrangement.

§This is a miscellaneous group including patients with poor mutational status (n = 3), high minimal residual disease by flow cytometry after induction or consolidation therapy (n = 3), prior myelodysplastic syndrome^ = I), and biphenotypic leukemia with t(4;6) and t(7;I4) (n = I).

more advanced disease status. Patients transplanted in CR1 had at least 1 of the following poor risk features: poor prognosis cytogenetics (n = 11), more than 1 cycle to achieve CR (n = 11), or several other factors in the remaining 8. Five patients had failed a previous autologous stem cell transplantation (ASCT). The median time from diagnosis to transplantation for patients transplanted in first CR was 6 months (range, 4 to 9). Median follow-up for surviving patients was 24 months (range: 3 to 79).

Cord Blood Unit and Transplant Characteristics

Table 1 shows the characteristics of CB units and those related to the transplant procedure.

Except for 4 patients who received a fully matched CB unit, the remaining 44 patients (92%) received an HLA-mismatched unit. Donor-recipient disparity in 1 and 2 of 6 antigens occurred in 19 patients (39%) and 25 patients (51%), respectively. One additional patient (2%) received a 3 antigen mismatched unit. The median number of TNC and CD341 cells infused was 2.2 x 107/kg (range: 1-4.4) and 1.2 x 105/kg (range: 0.09-6.09), respectively. Data on CD341 cells before freezing was available in 47 CB grafts, of which 46 (98%) had CD341 cells >0.6 x 105/kg and 40 (85%) had CD341 cells >1 x 105/kg, with a median of 1.6 x 105/kg. Seven patients (13%) received CB units with a major ABO blood group mismatch. Fourteen patients (29%) received KIR-ligand-incompatible CB units in the GVH direction.

Myeloid Engraftment

One patient died on day 19 after CBT without evidence of myeloid engraftment. One additional patient had a primary graft failure and underwent a second transplant from an HLA-mismatched family donor on day 47 after CBT. The remaining 47 patients experienced myeloid engraftment at a median time of 20 days (range: 11-57). The cumulative incidence at 57 days of myeloid engraftment was 96% (Figure 1). All patients with myeloid engraftment showed full donor chimerism at time of reconstitution.

In univariate analysis, the only variable influencing time to myeloid engraftment was CD341 cell dose before freezing with a best cutoff at 1.5 x 105/kg (Figure 1). The median time to myeloid engraftment was 18 and 23 days for patients receiving CB units with CD341 cells above and below 1.5 x 105/kg, respectively (P = .009) (Table 3).

Platelet Engraftment

Thirteen patients died between 19 to 250 days after transplant without platelet engraftment. The

Overall CI: 96%

Days after transplant

Figure 1. Cumulative incidence of neutrophil recovery after CBT, overall and according to CD34 cells before freezing (cutoff, 1.5 x l05/kg).

Table 3. Univariate and Multivariate Analysis for Engraftment and Nonrelapse Mortality in Study Population

Myelogenous Engraftment

Univariate

Platelet Engraftment

Univariate

Multivariate

Univariate

Multivariate

Variable Unfavorable P- Value Unfavorable P- Value P-Value Unfavorable P- Value P-Value

Age .4 .98 .4

Sex .8 .l .6

Weight .6 .l8 .4

CMV serology .6 .4 .3

Disease status at transplant .25 > first CR .04 .2

HLA compatibility .4 5-6/6 .03 .l7

ABO blood group mismatch .7 .6 Major .02

Donor-recipient sex match .4 .7 .7

KIR-ligand incompatibility l .7 .8

Year of transplantation .4 .3 .37

Conditioning regimen .5 .2 .5

Graft-versus-host disease .4 CSA + Pred 00l .3

prophylaxis #2.7 x l07/kg

No. of nucleated cells .4 0l7 #3.4 .03 .0l

before freezing #2.0 x l07/kg

No. of nucleated cells .98 .03 .l

infused

No. of CD34+ cells before #1.5 x l05/kg .009 #1.5 x l05/kg .0009 <.000l 2.0 x l05/kg .08

freezing #1.6 x l05/kg

No. of CD34+ cells infused - .4 .002 .l8

CMV indicates cytomegalovirus; KIR, killer cell immunoglobulin -like receptor.

remaining 36 patients had platelet engraftment at a median time of 62 days (range: 19-250). The cumulative incidence of platelet engraftment was 73% at 250 days.

Univariate analysis showed that disease status at transplant, degree of HLA mismatch, GVHD prophylaxis, and TNC and CD341 cell dose before freezing and at infusion had a significant impact on the cumulative incidence of platelet recovery (Table 3). In multivariate analysis, the only variable influencing platelet recovery was CD341 cell dose before freezing, with the best cutoff at 1.5 x 105. The median time to platelet engraftment was 85 and 47 days for patients who received CB units below and above 1.5 x 105/kg, respectively.

aGVHD occurred in 27 of 47 evaluable patients. The clinical grading of aGVHD was grade I in 15 patients, grade II in 5 patients, grade III in 5 patients, and grade IV in 2 patients. The median time to the development of aGVHD grade II to IV was 14 days (range: 7-57). The cumulative incidence of grade II to IV and grade III to IV aGVHD at day 100 after UCBT was 26% and 15%, respectively. Skin involvement was observed in 25 patients (grade II in 11 and grade III in 3), intestinal involvement in 9 patients (grade II in 2 and grade III in 2), and liver involvement in 4 patients (grade II in 1, grade III in 2, and grade IV in 1). Two patients died of aGVHD grade IV.

Seventeen of 39 patients at risk developed cGVHD. cGVHD was limited in 6 patients and extensive in 11 patients. The median time to development of

cGVHD was 141 days (range: 99-290). The 2-years cumulative incidence of overall and extensive cGVHD was 46% and 30%, respectively. Five patients with extensive cGVHD (45%) had complete resolution and discontinuation of immunosuppressive therapy including cyclosporine and/or prednisone. One patient died of pulmonary cGVHD.

No factor was associated with the incidence of aGVHD grade II to IV or III to IV. The only variable related to higher overall cGVHD was high TNC infused with the best cutoff at 2.8 x 107/kg (P = .004).

NRM and Causes of Death

Nineteen transplant-related deaths occurred at a median time of 114 days after transplantation (range: 19 to 2535). The causes of death were infection in 10 patients, GVHD in 3 (2 aGVHD and 1 chronic GVHD), hemorrhage in 3, secondary malignancy in 2 (1 Epstein-Barr virus (EBV)-related postransplantlym-phoproliferative disorder and 1 AML of donor origin), and primary graft failure in the remaining patient. Four of the 10 deaths attributable to infection were bacterial infections (1 Mycobacterium tuberculosis, 1 Escherichia coli, 1 Stenotrophomonas maltophilia, and 1 Acinetobacter baumanii), 5 invasive fungal infections (4 Aspergillus sp and 1 Candida krusei), and 1 leishmaniasis.

The cumulative incidence of NRM at day 100, and 2 years was 18% and 39%, respectively (Figure 2). In univariate analysis, NRM was significantly associated with major ABO incompatibility between donor and recipient, and TNC before freezing #3.4 x 107/kg

<5 0,7 ■D

'I 0,6

a) 0,5

2-year NRM: 39 %

0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48 Months after transplant

Figure 2. Cumulative incidence of nonrelapse mortality (NRM) and relapse (RR) after CBT.

(Table 3). In multivariate analysis TNC #3.4 x 107/kg was the only variable significantly associated with a higher NRM (P = .01).

Relapse

Nine patients relapsed at a median time of 7.5 months (range: 3 to 32). All relapsing patients died. The 2 years cumulative incidence of relapse was 19% (Figure 2). No factor was significantly associated with relapse rate. There was a trend for a lower relapse rate in patients receiving fludarabine-based conditioning regimens (P = .1) (Table 4). Of the 11 patients with extensive cGVHD, leukemia relapse after CBT was detected in 2 patients.

Twenty-one patients remained alive and leukemia-free after CBT at last follow up (range: 3-79 months). The overall LFS at 2 and 4 years were 42% (95% cumulative incident [CI], 27% to 57%) and 37%

(95% CI, 21% to 53%), respectively (Figure 3). In univariate analysis, disease status, HLA mismatch, ABO incompatibility, and TNC at infusion had a significant impact on LFS (Table 4). In multivariate analysis TNC #2 x 107/kg was the only variable significantly associated with lower LFS (P = .04) (Table 4).

When the analysis was restricted to patients transplanted in CR1 (n = 30), the 4-year overall LFS was 48% (95% CI, 28% to 68%). In this setting, those patients receiving TNC at infusion above and below 2 x 107/kg, the 4-year LFS rates were 75% and 25%, respectively (P = .03) (Figure 4).

DISCUSSION

This single-center study confirms that single-unit CBT from unrelated donors after myeloablative conditioning is a real alternative for adults with AML for whom a hematopoietic stem cell transplant is indicated. We were also able to identify CD341 cell dose before freezing as an independent factor associated with hematopoietic recovery, influencing both myeloid and platelet engraftment. TNC dose was associated with both NRM and LFS. These data may provide clinically useful information to improve the outcome of CBT in adults with poor-risk AML through better selection of both CB units and recipients.

Despite the important growth in CBT activity all over the world, information on disease-specific outcomes is still very limited. In fact, only 2 subsequent reports from the University of Tokyo [6,7] have reported specific data on CBT from unrelated donors in adults with AML. Two additional registry-based reports, 1 from Eurocord/EBMT [4] and another from the JMDP/JCBBN [8], have also analyzed CBT outcome in adults with acute leukemia (AML and ALL),

Table 4. Univariate and Multivariate Analysis for Relapse and Leukemia-Free Survival in the Study Population

Relapse

Leukemia-Free Survival

Univariate

Variable

Unfavorable

P- Value

Multivariate

P-Value

Univariate

Unfavorable

P- Value

Multivariate

P-Value

Age Sex

Weight CMV serology

Disease status at transplantat HLA compatibility ABO blood group mismatch Donor-recipient sex match KIR-ligand incompatibility Year of transplantation Conditioning regimen Graft-versus-host disease prophylaxis No. of nucleated cells before freezing No. of nucleated cells infused No. of CD34+ cells before freezing No. of CD34+ cells infused

> first CR

<2.0 x I07/kg

CMV indicates cytomegalovirus; KIR, killer cell immunoglobulin-like receptor.

Months after transplant

Figure 3. Kaplan-Meier estimate of leukemia-free survival (LFS) in 49 adults with AML undergoing CBT from unrelated donor.

but both were mainly focused on comparing CBT with BMT. Therefore, our results will be discussed in the context of this limited information on CBT in adults with AML.

Regarding the characteristics of patients and CB units of the present study compared with other similar reports, it should be noted that the median weight of patients in our series was higher (71 kg) than reported by the University of Tokyo [7] and Eurocord [4] (55 and 58 kg, respectively). It can be also highlighted the higher HLA disparities between donors and recipients in the Japanese study [7] compared with our series. Whereas we transplanted only 1 patient (2%) with 3 antigen mismatches, 35% of patients in the study of the University of Tokyo had similar or greater incompatibility (5% did not share 4 HLA antigens). An additional dissimilarity of our study when compared with the aforementioned studies is the higher fraction of patients transplanted in CR1. Nevertheless, all patients in this setting had at least 1 high-risk feature, with poor risk cytogenetics and/or $2 cycles of induction therapy to achieve CR being the most frequent factors (74%) that led to indicate an allogeneic SCT. For the remaining patients transplanted in CR1, other factors that have been recognized to confer bad prognosis

Months after transplant

Figure 4. Kaplan-Meier estimates of leukemia-free survival (LFS) according to total nucleated (TNC) cells infused (cutoff, 2 x l07/kg) in 30 adults with AML in first CR.

were present. This is the case of high minimal residual disease by flow cytometry after induction and/or consolidation [29], or displaying a poor mutational status [30]. In contrast with the University of Tokyo [7], no patient in our study was transplanted if they had intermediate cytogenetics only. Because of the potential impact on several outcomes, dissimilarities in the characteristics of patients and CB units should be taken into account to interpret the results of different studies.

In our study, as in that of the University of Tokyo, hematopoietic recovery in CBT recipients was significantly faster and graft failure was lower than in the 3 large registry-based retrospective studies carried out in Europe [4], Japan [8], and the United States [5]. Whereas the median time to neutrophil recovery was 20 days in our patients and 21 days in the study of the University of Tokyo, it was 27 and 28 days in 2 of the aforementioned registry-based studies that provided these data [4,5]. In addition, myeloid engraftment in the 2 single institutions were significantly higher (roughly 95%) than in the registry-based series (range: 70% to 77%). In both single-center studies, we found that a higher CD341 cell dose before freezing is the most important factor associated with faster hemato-poietic recovery. Furthermore, the TNC dose infused in our patients was similar to other reports in adults and significantly lower than in pediatric patients [31] undergoing CBT that used only the nucleated cell dose content for CB unit selection and resulted in a slower engraftment than in this report. Therefore, we can speculate that the selection of CB units with high number of CD341 cells, a criterion followed in our institution for guiding CB unit choice, could have been the main factor contributing to the improvement in rapidity and rate of engraftment. Unfortunately, data on CD34+ cell dose were not provided by the registry-based studies to confirm this hypothesis. However, the role of other factors, such as the conditioning regimen used, cannot be excluded. In this regard, those strategies designed to improve engraftment such as the use of 2 CB units [32] or direct intrabone infusion [33] have reported engraftment results that are not substantially different from our data and should compare with these single-center studies instead of registry data.

As it has been previously reported [4,5,8,34,35], we have confirmed a relatively low incidence of aGVHD and cGVHD after CBT. Only the series reported by Ooi et al. [7] observed a remarkably high incidence of aGVHD and cGVHD (81% for aGVHD grade II to IV and 84% for cGVHD). Nevertheless, it should be noted that this important difference in GVHD rate was mainly because of the incidence of aGVHD grade II and limited cGVHD. Interestingly, in our study, we found that the degree of HLA mismatch seems to have no influence on the occurrence of aGVHD or cGVHD, whereas high TNC dose was associated with the development of cGVHD.

Regarding short- and long-term NRM, our study shows higher rates (18% at day 100 and 39% at 2 years) than those reported in the study of the University of Tokyo (9% at day 100 and 10% at 5 years). However, the studies by Eurocord/EBMT [4] and the JMDP/ JCBBN [8] reported cumulative incidence of TRM at 2 years of 44% (for AML and ALL together) and 33% (for AML), respectively. Trying to scrutinize the reasons that might explain this difference in NRM, several factors should be considered. First, we found all the 5 patients with a previous autologous stem cell transplantation died, and also, the study of the University of Tokyo did not include patients previously autografted. An additional aspect to take into account is the higher mortality because of infection and hemorrhage observed in our study. Apart from some local factors, it is possible that the implementation of stricter preventive and therapeutic measures to manage infectious complications, with high impact in mortality [36], could improve outcomes.

Relapse rate was low and similar to the rates previously reported for patients with high- risk AML in the setting of bone marrow unrelated donor transplant [37] and CBT [7], confirming the high antileukemic efficacy of the procedure. Hence, overall long-term results in terms of event-free survival (EFS) were mainly influenced by NRM and the associated risk factors.

In conclusion, these results show that single-unit CBT from unrelated donors after MA conditioning is a curative treatment for a substantial number of patients with high-risk AML, particularly if transplant is performed with highly cellular units in patients in first CR. Cell dose should be the most important factor to consider when selecting CB units, both in terms of TNC and CD341 cells. More specific studies on adults with AML receiving CBT from unrelated donors are warranted to definitely establish the best donor and patients conditions that improve outcome and place this procedure in the therapeutic algorithm of this disease.

ACKNOWLEDGMENTS

The authors thank Shirley Weiss for data collection and management. Contributions: J.S., M.S., and G.S., conceived the study and interpreted the data; J.S., M.S., and G.S. wrote the paper; J.S. performed the statistical analyses; S. S., I. L., P.M., L.S., D.P., L. L., G. M., J. P., I. J., J. M., J. R., F. M., M. R., I. L., A. M., and S. C. reviewed the manuscript and contributed to the final draft.

Financial disclosure: The authors have nothing to disclose.

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